Electrolysis products, reactive oxygen species and ATP loss contribute to cell death following irreversible electroporation with microsecond-long pulsed electric fields

Membrane permeabilization and thermal injury are the major cause of cell death during irreversible electroporation (IRE) performed using high electric field strength (EFS) and small number of pulses. In this study, we explored cell death under conditions of reduced EFS and prolonged pulse application, identifying the contributions of electrolysis, reactive oxygen species (ROS) and ATP loss. We performed ablations with conventional high-voltage low pulse (HV-LP) and low-voltage high pulse (LV-HP) conditions in a 3D tumor mimic, finding equivalent ablation volumes when using 2000 V/cm 90 pulses or 1000 V/cm 900 pulses respectively. These results were confirmed by performing ablations in swine liver. In LV-HP treatment, ablation volume was found to increase proportionally with pulse numbers, without the substantial temperature increase seen with HV-LP parameters. Peri-electrode pH changes, ATP loss and ROS production were seen in both conditions, but LV-HP treatments were more sensitive to blocking of these forms of cell injury. Increases in current drawn during HV-LP was not observed during LV-HP condition where the total ablation volume correlated to the charge delivered into the tissue which was greater than HV-LP treatment. LV-HP treatment provides a new paradigm in using pulsed electric fields for tissue ablation with clinically relevant volumes.

Non-Contact Irreversible Electroporation in the Esophagus With a Wet Electrode Approach

Our objective was to develop a technique for performing irreversible electroporation (IRE) of esophageal tumors while mitigating thermal damage to the healthy lumen wall. We investigated noncontact IRE using a wet electrode approach for tumor ablation in a human esophagus with finite element models for electric field distribution, joule heating, thermal flux, and metabolic heat generation. Simulation results indicated the feasibility of tumor ablation in the esophagus using an catheter mounted electrode immersed in diluted saline. The ablation size was clinically relevant, with substantially lesser thermal damage to the healthy esophageal wall when compared to IRE performed by placing a monopolar electrode directly into the tumor. Additional simulations were used to estimate ablation size and penetration during noncontact wet-electrode IRE (wIRE) in the healthy swine esophagus. A novel catheter electrode was manufactured and wIRE evaluated in seven pigs. wIRE was performed by securing the device in the esophagus and using diluted saline to isolate the electrode from the esophageal wall while providing electric contact. Computed tomography and fluoroscopy were performed post-treatment to document acute lumen patency. Animals were sacrificed within four hours following treatment for histologic analysis of the treated esophagus. The procedure was safely completed in all animals; post-treatment imaging revealed intact esophageal lumen. The ablations were visually distinct on gross pathology, demonstrating full thickness, circumferential regions of cell death (3.52 ± 0.89 mm depth). Acute histologic changes were not evident in nerves or extracellular matrix architecture within the treatment site. Catheter directed noncontact IRE is feasible for performing penetrative ablations in the esophagus while avoiding thermal damage.

Observation of Antiferromagnetic Magnon Pseudospin Dynamics and the Hanle Effect

We report on experiments demonstrating coherent control of magnon spin transport and pseudospin dynamics in a thin film of the antiferromagnetic insulator hematite utilizing two Pt strips for all-electrical magnon injection and detection. The measured magnon spin signal at the detector reveals an oscillation of its polarity as a function of the externally applied magnetic field. We quantitatively explain our experiments in terms of diffusive magnon transport and a coherent precession of the magnon pseudospin caused by the easy-plane anisotropy and the Dzyaloshinskii-Moriya interaction. This experimental observation can be viewed as the magnonic analog of the electronic Hanle effect and the Datta-Das transistor, unlocking the high potential of antiferromagnetic magnonics toward the realization of rich electronics-inspired phenomena.

Sonographic and 3T-MRI-based evaluation of the tongue in ALS

A few systematic imaging studies employing ultrasound (HRUS) and magnetic resonance imaging (MRI) have suggested tongue measures to aid in diagnosis of amyotrophic lateral sclerosis (ALS). The relationship between structural tongue alterations and the ALS patients' bulbar and overall motor function has not yet been elucidated. We here thus aimed to understand how in-vivo tongue alterations relate to motor function and motor function evolution over time in ALS. Our study included 206 ALS patients and 104 age- and sex-matched controls that underwent HRUS and 3T MRI of the tongue at baseline. Sonographic measures comprised coronal tongue echointensity, area, height, width and height/width ratio, while MRI measures comprised sagittal T1 intensity, tongue area, position and shape. Imaging-derived markers were related to baseline and longitudinal bulbar and overall motor function. Baseline T1 intensity was lower in ALS patients with more severe bulbar involvement at baseline. Smaller baseline coronal (HRUS) and sagittal (MRI) tongue area, smaller coronal height (HRUS) and width (HRUS) as well as more rounded sagittal tongue shape predicated more rapid functional impairment - not only of bulbar, but also of overall motor function - in ALS. Our results suggest that in-vivo sonography und MRI tongue measures could aid as biomarkers to reflect bulbar and motor function impairment.

Spin Transport in a Magnetic Insulator with Zero Effective Damping

Applications based on spin currents strongly rely on the control and reduction of their effective damping and their transport properties. We here experimentally observe magnon mediated transport of spin (angular) momentum through a 13.4-nm thin yttrium iron garnet film with full control of the magnetic damping via spin-orbit torque. Above a critical spin-orbit torque, the fully compensated damping manifests itself as an increase of magnon conductivity by almost 2 orders of magnitude. We compare our results to theoretical expectations based on recently predicted current induced magnon condensates and discuss other possible origins of the observed critical behavior.

Gross and histopathologic diagnoses from North Atlantic right whale Eubalaena glacialis mortalities between 2003 and 2018

Seventy mortalities of North Atlantic right whales Eubalaena glacialis (NARW) were documented between 2003 and 2018 from Florida, USA, to the Gulf of St. Lawrence, Canada. These included 29 adults, 14 juveniles, 10 calves, and 17 of unknown age class. Females represented 65.5% (19/29) of known-sex adults. Fourteen cases had photos only; 56 carcasses received external examinations, 44 of which were also necropsied. Cause of death was determined in 43 cases, of which 38 (88.4%) were due to anthropogenic trauma: 22 (57.9%) from entanglement, and 16 (42.1%) from vessel strike. Gross and histopathologic lesions associated with entanglement were often severe and included deep lacerations caused by constricting line wraps around the flippers, flukes, and head/mouth; baleen plate mutilation; chronic extensive bone lesions from impinging line, and traumatic scoliosis resulting in compromised mobility in a calf. Chronically entangled whales were often in poor body condition and had increased cyamid burden, reflecting compromised health. Vessel strike blunt force injuries included skull and vertebral fractures, blubber and muscle contusions, and large blood clots. Propeller-induced wounds often caused extensive damage to blubber, muscle, viscera, and bone. Overall prevalence of NARW entanglement mortalities increased from 21% (1970-2002) to 51% during this study period. This demonstrates that despite mitigation efforts, entanglements and vessel strikes continue to inflict profound physical trauma and suffering on individual NARWs. These cumulative mortalities are also unsustainable at the population level, so urgent and aggressive intervention is needed to end anthropogenic mortality in this critically endangered species.

Observation of the spin Nernst effect

The observation of the spin Hall effect triggered intense research on pure spin current transport. With the spin Hall effect, the spin Seebeck effect and the spin Peltier effect already observed, our picture of pure spin current transport is almost complete. The only missing piece is the spin Nernst (-Ettingshausen) effect, which so far has been discussed only on theoretical grounds. Here, we report the observation of the spin Nernst effect. By applying a longitudinal temperature gradient, we generate a pure transverse spin current in a Pt thin film. For readout, we exploit the magnetization-orientation-dependent spin transfer to an adjacent yttrium iron garnet layer, converting the spin Nernst current in Pt into a controlled change of the longitudinal and transverse thermopower voltage. Our experiments show that the spin Nernst and the spin Hall effect in Pt are of comparable magnitude, but differ in sign, as corroborated by first-principles calculations.

A Comparative Study of Ablation Boundary Sharpness After Percutaneous Radiofrequency, Cryo-, Microwave, and Irreversible Electroporation Ablation in Normal Swine Liver and Kidneys

PURPOSE

To compare ablation boundary sharpness after percutaneous radiofrequency ablation (RFA), cryoablation (CA), microwave ablation (MWA) and irreversible electroporation (IRE) ablation in normal swine liver and kidney.

MATERIALS AND METHODS

Percutaneous CT-guided RFA (n = 5), CA (n = 5), MWA (n = 5) and IRE (n = 5) were performed in the liver and kidney of four Yorkshire pigs. Parameters were chosen to produce ablations 2-3 cm in diameter with a single ablation probe. Contrast-enhanced CT imaging was performed 24 h after ablation, and animals were killed. Treated organs were removed and processed for histologic analysis with hematoxylin and eosin, and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL). Three readers independently analyzed CT, H&E and TUNEL stained images of the ablation boundary to delineate regions of (1) viable cells, (2) complete necrosis or (3) mixture of viable and necrotic cells which was defined as the transition zone (TZ). The width of TZ was compared across the techniques and organs.

RESULTS

Ablations appeared as non-contrast-enhancing regions on CT with sharp transition to enhancing normal tissue. On TUNEL stained slides, the mean width (μm) of the TZ after MWA was 319 ± 157 in liver and 267 ± 95 in kidney, which was significantly lower than RFA (811 ± 477 and 938 ± 429); CA (452 ± 222 and 700 ± 563); and IRE (1319 ± 682 and 1570 ± 962) (all p < 0.01). No significant differences were observed between the organs.

CONCLUSION

Under similar conditions, the width of the TZ at the ablation boundary varies significantly between different ablation techniques.

Acute and delayed bleeding requiring embolization after image-guided liver biopsy in patients with cancer

PURPOSE

To report incidence of acute versus delayed presentations of bleeding requiring embolization after focal liver biopsy, in correlation with angiographic findings and treatment success rates. The available literature will be reviewed as well.

MATERIALS AND METHODS

Health Insurance Portability and Accountability Act-compliant institutional review board approved retrospective review of 2180 consecutive patients undergoing 2335 targeted liver biopsies at a tertiary-care cancer center. Hepatic arterial embolization episodes within 30days from biopsy were identified via radiology PACS. Electronic medical record review was performed for indication of embolization and postembolization clinical course.

RESULTS

The incidence of postbiopsy bleeding requiring embolization was 0.5% (12/2335 biopsies). In those with bleeding, 1/12 (8%) had no hepatic arterial findings at angiography. Angiographic hepatic arterial findings resolved after embolization in 11/11 patients (100% technical success). Bleeding ceased after embolization in 10/12 patients (83% clinical success). Complications were seen in 2/12 (17%) patients: cholecystitis and hepatic infarct, respectively. Delayed presentation of bleeding (defined as >24h postbiopsy) occurred in 5/12 (42%) patients; the longest latency was 12days.

CONCLUSION

The overall incidence of bleeding requiring embolization in our population was 0.5%. This complication rate compares favorably to the 0-4.2% (median: 0.29%) rate quoted in the available, heterogeneous, literature on this topic. Delayed presentation occurred in almost half of patients. Arterial embolization carries excellent technical and clinical success rates.

Feasibility of a Modified Biopsy Needle for Irreversible Electroporation Ablation and Periprocedural Tissue Sampling

OBJECTIVES

To test the feasibility of modified biopsy needles as probes for irreversible electroporation ablation and periprocedural biopsy.

METHODS

Core biopsy needles of 16-G/9-cm were customized to serve as experimental ablation probes. Computed tomography-guided percutaneous irreversible electroporation was performed in in vivo porcine kidneys with pairs of experimental (n = 10) or standard probes (n = 10) using a single parameter set (1667 V/cm, ninety 100 µs pulses). Two biopsy samples were taken immediately following ablation using the experimental probes (n = 20). Ablation outcomes were compared using computed tomography, simulation, and histology. Biopsy and necropsy histology were compared.

RESULTS

Simulation-suggested ablations with experimental probes were smaller than that with standard electrodes (455.23 vs 543.16 mm²), although both exhibited similar shape. Computed tomography (standard: 556 ± 61 mm², experimental: 515 ± 67 mm²; P = .25) and histology (standard: 313 ± 77 mm², experimental: 275 ± 75 mm²; P = .29) indicated ablations with experimental probes were not significantly different from the standard. Histopathology indicated similar morphological changes in both groups. Biopsies from the ablation zone yielded at least 1 core with sufficient tissue for analysis (11 of the 20).

CONCLUSIONS

A combined probe for irreversible electroporation ablation and periprocedural tissue sampling from the ablation zone is feasible. Ablation outcomes are comparable to those of standard electrodes.

Feasibility of catheter-directed intraluminal irreversible electroporation of porcine ureter and acute outcomes in response to increasing energy delivery

PURPOSE

To evaluate the feasibility of focal intraluminal irreversible electroporation (IRE) in the ureter with a novel electrode catheter and to study the treatment effects in response to increasing pulse strength.

MATERIALS AND METHODS

Five IRE treatment settings were each evaluated twice for the ablation of normal ureter in 5 Yorkshire pigs (n = 1-4 ablations per animal; total of 10 ablations) with the use of a prototype device under ultrasound and fluoroscopic guidance. Animals received unilateral or bilateral treatment, limited to a maximum of 2 ablations in any 1 ureter. Treatment was delivered with increasing pulse strength (from 1,000 V to 3,000 V in increments of 500 V) while keeping the pulse duration (100 μs) and number of pulses (n = 90) constant. Ureter patency was assessed with antegrade ureteropyelography immediately following treatment. Animals were euthanized within 4 hours after treatment, and treated urinary tract was harvested for histopathologic analysis with hematoxylin and eosin and Masson trichrome stains.

RESULTS

IRE was successfully performed in all animals, without evidence of ureteral perforation. Hematoxylin and eosin analysis of IRE treatments demonstrated full-thickness ablation at higher field strengths (mucosa to the adventitia). Masson trichrome stains showed preservation of connective tissue at all field strengths.

CONCLUSIONS

Intraluminal catheter-directed IRE ablation is feasible and produces full-thickness ablation of normal ureters. There was no evidence of lumen perforation even at the maximum voltages evaluated.

Percutaneous ablation of peribiliary tumors with irreversible electroporation

PURPOSE

To assess biliary complications after irreversible electroporation (IRE) ablation of hepatic tumors located < 1 cm from major bile ducts.

MATERIALS AND METHODS

A retrospective review was conducted of all percutaneous IRE ablations of hepatic tumors within 1 cm of the common, left, or right hepatic ducts at a single institution from January 2011 to September 2012. Computed tomography imaging performed before and after treatment was examined for evidence of bile duct dilatation, stricture, or leakage. Serum bilirubin and alkaline phosphatase levels were analyzed for evidence of biliary injury.

RESULTS

There were 22 hepatic metastases in 11 patients with at least one tumor within 1 cm of the common, left, or right hepatic duct that were treated with IRE ablations in 15 sessions. Median tumor size treated was 3.0 cm (mean, 2.8 cm ± 1.2, range, 1.0-4.7 cm). Laboratory values obtained after IRE were considered abnormal after four treatment sessions in three patients (bilirubin, 2.6-17.6 mg/dL; alkaline phosphatase, 130-1,035 U/L); these abnormal values were transient in two sessions. Two patients had prolonged elevation of values, and one required stent placement; both of these conditions appeared to be secondary to tumor progression rather than bile duct injury.

CONCLUSIONS

This clinical experience suggests that IRE may be a treatment option for centrally located liver tumors with margins adjacent to major bile ducts where thermal ablation techniques are contraindicated. Further studies with extended follow-up periods are necessary to establish the safety profile of IRE in this setting.

Comparison of simulation-based treatment planning with imaging and pathology outcomes for percutaneous CT-guided irreversible electroporation of the porcine pancreas: a pilot study

PURPOSE

To investigate the reliability of simulations for planning pancreatic irreversible electroporation (IRE) ablations compared with computed tomography (CT) and pathology outcomes in an animal model.

MATERIALS AND METHODS

Simulations were performed varying treatment parameters, including field strength (1.5-2.5 kV/cm), pulse number (70-90 pulses), and pulse length (70-100 µs). Pancreatic IRE was performed in six pigs under CT guidance. Two animals each were sacrificed for histology after 1 day, 14 days, and 28 days. Follow-up CT scans were performed on day 0, day 1, day 14, and day 28. Biochemical markers were collected before the procedure, 1 day after the procedure, and 14 days after the procedure.

RESULTS

All ablation zones could be visualized on CT scan immediately after the procedure and on day 1 follow-up CT scan, and all animals survived until the designated endpoints. Histopathology revealed necrosis and edema on day 1 and fibrosis and glandular atrophy after 28 days. Blood vessels close to the ablation zone appeared normal. Laboratory analysis indicated mild to moderate amylasemia and lipasemia with normalization after 14 days. The ablation size on CT scan measured a mean (± SD) 146% ± 18 (day 0, P < .126) and 168% ± 18 (day 1, P < .026) of the simulation and on pathology measured 119% ± 10 (day 1, not significant) of the simulation.

CONCLUSIONS

Results from simulations for planning IRE ablations, CT, and pathology may differ from each other. Ablation zones on CT and pathology appear larger than simulated, suggesting that clinically used treatment planning may underestimate the ablation size in the pancreas.

Evaluation of an endorectal electrode for performing focused irreversible electroporation ablations in the Swine rectum

PURPOSE

To study the feasibility of a novel endorectal electrode for the creation of focal ablations of the rectal wall with the use of irreversible electroporation (IRE).

MATERIALS AND METHODS

A monopolar electrode with a grounding pad (10 ablations in five pigs) and a bipolar electrode (two ablations in one pig) were evaluated in healthy swine rectum. A two-dimensional model of the electrode in the rectum was created and used to solve the Laplace equation to determine field strength. Simulation was used to identify treatment settings for superficial ablation (mucosal layers) or transmural ablation of rectal wall. Animals were euthanized within 4 hours after treatment.

RESULTS

Treatment was successfully completed without treatment-related complications. Eleven of 12 lesions were successfully located and extracted for pathologic analysis. All lesions were characterized by necrotic cell death with mild inflammation and hyperemia, with a sharp demarcation between ablated and adjacent normal tissue. Depth of lesions corresponded with numeric simulation. Histologic analysis and measurements indicated that lesion creation with the superficial treatment setting resulted in ablation of mucosal and submucosal layers with superficial or no injury to the muscularis propria (9.97 mm ± 0.31 length, 3.3 mm ± 2.92 depth), and that lesion creation with the transmural treatment setting resulted in full-thickness ablation (12.43 mm ± 3.85 length, 4.97 mm ± 2.89 depth) of the rectal wall.

CONCLUSIONS

An endorectal electrode can be used to deliver IRE and create limited focal ablations in the rectal wall. Treatment parameters can be determined through numeric modeling to control the depth of penetration of ablation.

The uraemic retention solute para-hydroxy-hippuric acid attenuates apoptosis of polymorphonuclear leukocytes from healthy subjects but not from haemodialysis patients

BACKGROUND

Disturbed polymorphonuclear leukocyte (PMNL) apoptosis contributes to the dysregulation of the non-specific immune system in uraemia. Intracellular Ca(2+) modulates PMNL apoptotic cell death. We investigated the effect of para-hydroxy-hippuric acid (PHA), an erythrocyte plasma membrane Ca(2+)-ATPase inhibitor accumulating in uraemic sera, and of cyclopiazonic acid (CPA), an inhibitor of the sarko/endoplasmatic Ca(2+)-ATPase, on PMNL apoptosis.

METHODS

Apoptosis of PMNLs from healthy subjects and from haemodialysis (HD) patients was assessed after incubation for 20 h by evaluating morphological features under the fluorescence microscope and by measuring the DNA content and caspase activities by flow cytometry. The intracellular calcium concentration ([Ca(2+)](i)) was determined by measurement of fura-2 fluorescence using the 340/ 380 nm dual wavelength excitation.

RESULTS

Spontaneous apoptosis of PMNLs from healthy subjects and from HD patients did not differ. PHA significantly attenuated, while CPA increased, the apoptotic cell death of PMNLs from healthy subjects. The PHA effect was not observed with PMNLs from HD patients, irrespective of whether the blood was drawn before or after HD treatment. Baseline [Ca(2+)](i) was increased in PMNLs obtained from HD patients before dialysis but reversed after dialysis. The PHA effects were not mediated via [Ca(2+)](i). The chemotactic peptide N-formyl-L-methionyl-L-leucyl-L-phenylalanine (fMLP) induced a [Ca(2+)](i) increase and reduced PMNL survival. Extracellular Ca(2+) did not affect CPA- and fMLP-induced apoptosis.

CONCLUSIONS

PHA, without affecting [Ca(2+)](i), attenuates apoptosis of healthy but not of uraemic PMNLs. CPA and fMLP enhance PMNL apoptosis independently of Ca(2+) influx.

Effects of Tamm-Horsfall protein on polymorphonuclear leukocyte function

BACKGROUND

Tamm-Horsfall protein (THP), a glycoprotein produced exclusively by renal tubular cells, is thought to be involved in several inflammatory disorders such as bacterial interstitial nephritis as well as in defence against uropathogenic microorganisms. The specific effects of THP on inflammatory cells, however, are not yet well known. Therefore, the present study investigates the effects of THP in its soluble form on distinct polymorphonuclear leukocyte (PMNL) functions.

METHODS

PMNL were isolated from the venous blood of healthy adult donors and incubated at low THP concentrations (70-350 ng/ml), resembling plasma concentrations, and at high THP concentrations (1.75-8.75 micro g/ml), resembling urinary concentrations.

RESULTS

High (urinary) THP concentrations inhibited PMNL apoptosis and chemotaxis and stimulated PMNL phagocytosis, while low (plasma) THP concentrations increased PMNL chemotaxis.

CONCLUSIONS

These data indicate that THP influences several PMNL functions, suggesting a crucial immunomodulatory role for this glycoprotein in host defence mechanisms of the kidney and genitourinary tract.

Standardized system for quantifying residual dirt on medical appliances cleansed in hospital washers--disinfectors: dirt detection by different methods

An easy-to construct, easy-to-operate standardized system was developed for determining the residual biological contamination of surgical instruments, endoscopes and other medical appliances subjected to hospital cleansing and/or disinfection. It consists of standard-sized pieces of glass, metal or endoscope plastic--dirt carriers--either bare or enclosed in truncated Eppendorf caps to simulate hard-to-access conditions. The surface of the carriers is covered with model dirt simulating biological contamination and the carriers are then affixed to sturdy metal holders. Conventional model dirt were found to peel or flake off the carrier surface, lowering the precision of residual soil determination. A newly developed model dirt consisting of liver mash, lactose and sunflower oil and exhibiting low tendency to peel off surfaces was therefore used. The whole setup was subjected to chemical or enzymic cleansing programs at elevated temperature in hospital washer-disinfectors of two types, and the residual dirt after cleansing was determined by three methods. The method using toxicant-doped dirt that quenches the luminescence of an indicator bacterium Photobacterium phosphoreum gave satisfactory data under laboratory conditions but with hospital-washed samples it exhibited excessive fluctuations caused by bacterium--dirt interactions and by physical influences. Both other methods gave better results but displayed some process sensitivity. The luciferin-luciferase-based ATP bioluminescence assay sometimes gave low or even negative dirt level values and showed a low effect of reduced dirt accessibility on cleansing of metal carriers. The Bradford protein assay showed about equal cleansing efficiency for both easily and poorly accessible carriers after enzymic cleansing. Our system can be used for determining low levels of residual contamination of medical appliances after cleansing/disinfection and assessing the efficiency of commercial washer-disinfectors; its efficiency can be further increased by using a cleansing process-insensitive method for soil detection and quantification.

[Risk factors in hyperlipidemic patients with coronary heart disease one year after PTCA]

The reduction of modifiable risk factors in hyperlipidemic patients with coronary heart disease (CHD) receiving standard medical care in Germany has not been evaluated before. We identified all patients < 65 yrs of age with marked hyperlipidemia (Cholesterol (Chol) > 250 mg/dl, HDL < 20% Chol) among all patients who underwent PTCA during defined periods 1991/92 in the Cardiology department of the Heinrich-Heine-University. The study patients (n = 93, age 54 +/- 8 yrs, 75 men, 18 women) were evaluated 13 +/- 2 months after PTCA for modification of their risk factors, treatments, knowledge, medications and dietary habits with a structured questionnaire and a 5-day dietary protocol. At follow-up Chol and LDL were significantly reduced from 299 +/- 47 to 253 +/- 43, and from 228 +/- 47 to 189 +/- 42 mg/dl, respectively (p < 0.001). 10% of patients had an LDL < 135 mg/dl. In contrast, HDL (43 +/- 9 mg/dl) and triglycerides (242 +/- 138 mg/dl), the percentage of smokers (40%), of overweight patients (38%) and of patients with elevated blood pressure (43%) remained unchanged. During the observation period the number of contacts with physicians was high (12 (1-40)). 32% of patients participated in dietary counselling by a dietician and 42% in an in-patient rehabilitation programme. In 2/3 of patients the knowledge related to hyperlipidemia and a lipid-lowering diet was good. However, according to the dietary protocols the fat intake was high (37 +/- 7% of total calories). Lipid lowering drugs had been prescribed in 68% of patients, predominantly as monotherapy and in low dosage.(ABSTRACT TRUNCATED AT 250 WORDS)